Rev. Med. Chir. Soc. Med. Nat, lagi~2018—vol. 122, no. 1 SURGERY ORIGINAL PAPERS MANAGEMENT OF RENAL COLIC DURING PREGNANCY Irina Negru', Alexandra Pangal *, C. Pricop'”, Elena Mibileeanu, C. Costichescu’, D. Negru “Grigore T. Popa” University of Medicine and Pharmacy Iasi Faculty of Medicine 4, Depastwent of Surgery (I) 2, Department of Mother and Child Medicine “corresponding author. E-mail: bobapricop@yalioo.com, MANAGEMENT OF RENAL COLIC DURING PREGNANCY (Abstract): The disgnosis of| ‘urological diseases in pregnancy involves particularities requiring both the knowledge of the ‘pathophysiological mechanisms of the respective diseases and a experience of the urologist and gynecologist in assessing the physiologiesl conditions of pregnancy. Aim: To identify the specific features of renal colic in pregnant wowea, inthe context ia which the urologieal assessment of them is not mandatory. Material and methods: The study included a group of 86 pregnant women diagnosed with urological diseases and renal colic as their msin symp: tom, Results: There are two major difficulties faced by uologists in these cases: festly, the impossibility of conduct tions to determine the location and type of the obstruction and, on secondly, tie ureteral catheterization and insertion of the ureteral catheter in the absence of adequate fuoraseopie control. Conelustons: The urologists expe- rionce is decisive in establishing intraoperatively ifthe introduction of the ureteric probe is possible, the risk of a ureteral perforstion with severe consequences requiring a percutaneous nepluostomy to be performed under ultrasound guidance, Keywords: PREGNANCY, RE- NAL COLIC, URINARY DISEASES. ‘During normal pregnaney there are pro- found changes in the genitourinary tract affecting the pregnant woman, Manage- ment of urological emergencies during pregnancy remains a challenge because clinical signs are subtle diagnostic tools and treatment options are limited. ‘Mild symptoms of urinary tract infec- tion, urolithiasis or hematuria can progress to true medical emergencies with devastat- ing results for the mother and the fetus if they are not diagnosed and treated promptly @. The clinical picture of urological condi- tions during pregnancy is like the manifesta- tions of these diseases in other categories of patients, but differences may occur in their progression and complications through f= fects for both mother and fetus. Urological disorders that may occur during pregnancy are acute hydronephrosis, of pregnancy, infections, urinary lithiasis, kidney failure, and clinically these mani- festations are dominated by pain, septic status or symptoms associated with im- paired renal function. ‘The aim of this study was to evaluate the issue of the diagnosis of certainty and 109Irina Negru et al the optimal therapeutic choice, related to a symptom that affects relatively frequently (11-20%) pregnant patients - renal coli. Because the number of patieuts presenting to urology clinics is increasing, it is neces- sary to standardize the methods for diagno- sis and treatment of these diseases, with the implementation of a patient management protocol. MATERIAL AND METHODS This retrospective study was performed in a group of 86 patients of different gesta- tional age that experienced this symptom. ‘The reasous for the presentation, age of the patients, gestational age, and the differen- tial diagnosis were considered, In this research, the STATISTICA. pro- tam, dedicated to medical research, was used for statistical data processing. The following tests were used: ANOVA, Scheffé, Pearson, Mantel-Haenszel, Fisher test, and specific correlation tests for quan- titative and for qualitative variables, Following these tests, the main parame- ters of interest were discussed and, according to their values, the conclusions were drawn, RESULTS The analysis of the age of patients with ological disorders during pregnancy r2- vealed « high frequency of cases between the age of 25 and 30 years (35.76%). Com- parable frequencies were recorded for the age groups 15-20 years - 15.15%, 30-35 years - 16.97%, and 20-25 years - 25.45%. A lower incidence of urological disease in pregnancy was found in patients over 35 years of age. There was a high frequency of eases in the second and third trimester of pregnan- cy, with a very low number of preguant ‘women in the first trimester of pregnancy - 9.09% (fig. 1). Gestational age 0 20 40 60 % Fig. 1. Distribution of cases by age of pregnancy ‘The number of pregnancies has a ho- mogeneous distribution, the highest fre- quency being found for cases with 1 or 2 110 pregnancies, representing 69.09%. Preg- ‘nant women at the 3-rd pregnancy account- ed for 30.91% of the study group (tab. 1).‘Management of renal colle during preguaney TABLE I Statistical indicators of the number of pregnancies in the study group “Average value Average of the number Std. Dev. 959% +9596 of pregnancies zs 197 Std. Er Min Max Q28 Median Q7S 09 The main reason for admission was the presence of collateral lumbar pain, which was identified in 82 cases. Absence of lumbar pain was very rare, in just 4 cases. The diagnosis on admission was ureterohydronephrosis in 52.12% of cases, infected ureterohydronephrosis in 26.67%, and acute pyelonephritis in 15.15% of pregnant women. A diagnosis of lumbar ureteral calculi was made in 3.3% of cases and of pelvic ureteral calculi in 3.03% (fig. 2) DIAGNOSIS AT ADMISSION Pedic ui Ler Fig. 2. Distribution of cases based on patient The urological history of pregnant women in the studied group was most fre- quently represented by the spontancous elimination of calculi (8.48%) and histo- logical documented lithiasis episode (2.42%) In our study most, pregnant women did 20° 60 gnosis not have a history of urinary disease (89.09%), which shows that pregnancy makes it that the pathological urological aspects that were clinically silent before pregnancy to become clinically manifest. In this study, the results of the multiple correlations were considered considering utthe changes in the admission profile of pregnant women with urological disorders ‘The insignificant value of the significance Irina Negru et al ble indicates that besides the factors under study there are no other predictive factors in determining the pursued profile (tab. I, level (p) calculated for the intercept varia- fig. 3) Lumbar pain was located on the right side in 43.64% of pregnant women in this, 42 Fig. 3. Statistical t-values inthe multiple correlation TABLE IL Multiple correlation of pregnancy age vs. cinteal aspects on admission ‘Coeticient ? or su. Paral ae 2886 tora correlation comvelation wets) er Gey confident Intercept os40s18 wane > 06T eS oraie2s 0 0.000132 5 DISISO_SSOTE ODES 3 Renal colle 0.799008 C1180 #0 e 0.00023 MiswREIE ag OTT D.19000 wasn nme ° 1 oserizo | OTe wpe 0.001879 eves, shiver t ° 5 on oae7 00487 089137 0.0586 | Trimester eotate ee ever, ser ester ones ‘Sader phenomera smacroferoeope Pee, of the age of pregnancy vs. clinical findings on admission study, while in 18.79% it was bilateral Left-side location was reported in 35.15%‘Management of renal colle during preguaney of cases (fig. 4). lh Fig. 4, Clinical aspects on admission - lumbar pain vs. trimester of pregnancy DISCUSSION Renal colic on admission was particn- larly noted in patients in the second tri- ester of pregnancy (52.17%), the results demonstrating a significant correlation between the age of pregnancy and the inc dence of lumbar pain (7 = 6.14, p = 0.036, 989% C1), The results of the study are con- sistent with literature data (2), The statistical data show that the inci- dence of rological diseases during preg- nancy is significantly higher in primiparas ‘women (35.15%) than in the other pregnant categories studied. The clinical findings on admission have shown a significant correlation with the age of pregnancy, a conclusion demonstrated by the results of the multiple correlation test 3). In other words, the age of pregnancy significantly influences the clinical aspect of pregnancy-related urological conditions. To highlight the most relevant clinical and laboratory findings depending on gestation age, multivariate analysis was used The results of multivariate analysis in- dicate the predictive factors of the profile of pregnant women with urological disor- der and gestational age. Correlation analysis using nonparamet- rie tests demonstrated the association be- tween the presence of lumbar pain and the trimester of pregnancy by the high value of the non-parametric correlation coefficient and low significance level of the test. In statistical estimations a 95% confidence interval was used, Ureteral calculi during pregnancy repre- sent not only a diagnostic challenge, but also a management dilemma, Some studies report an incidence of symptomatic uro- lithiasis during pregnancy of 0.35%, accur- ring especially in the third trimester of pregnancy (55.5%) (4) ‘The reported incidence of symptomatic nephrolithiasis during pregnancy varies greatly between | in 244 pregnancies to 1 in 1,240 pregnancies (5). The occurrence of urolithiasis during pregnancy is a risk not only for the mother but also for the fetus and may be a factor which contrib- utes to premature birth. The diagnosis during pregnancy is difficult, primarily because of limitations of X-ray use and physiological hydronephrosis during preg- nancy (6). In cases requiring invasive treatment, double-J stent or percutaneous nephrostomy may be used, which are the less invasive techniques for urinary drain- age. The insertion of a double-I catheter can be performed under control until the end of pregnancy, Percutaneous nephros- tomy can also be performed with local ‘anesthesia under ultrasound guidance, realizing an external drainage without irritation of the bladder. In sare situations where obstruction is bilateral, the colic is accompanied by oligu- ria of even anuria, These urinary phenome- ‘ua may be accompanied by reflexive diges- tive manifestations, namely nausea, vomit- 113Irina Negru et al ing, or ileus which may sometimes be se- vere, These symptoms may be explained by the direct compression in pregnancy on the celiac plexus and the phenomena of angio- genesis and vascular hypertrophy. Renal colic is the most common mani festation of acute hydronephrosis in preg- nancy and occurs in most cases on the right side. In contrast to colic of lithiasis where there is typically no antalgic position for the patient, in the colic of hydronephrosis the pain improves or even disappears if the pregnant woman is lying on the opposite side to the painful one (7) During pregnaney, symptomatic uro- lithiasis associated with ureteral obstruc- tion and upper urinary tract infection is a ‘major urological emergency that may cause perineal urosepsis, or even patient death. Also, the preseace of urinary calculi can cause premature rupture of membranes and premature birth in a percentage ranging from 2.9% to 7%, presenting a high degree of risk for the fetus The presence of an associated pathology in pregnant women, e.g. hypothyroidism, further complicates the situation and out comes of treatment, raising doubts about the continuation of pregnancy (8). These reasons lead to the conclusion that although urolithiasis is a relatively rare condition during pregnancy, its correct approach requires a very good collabora- tion between obstetricians, urologists, radi- ologists and anesthetists. Renal colic during pregnancy can be de- termined by both acute gestational hydro- nephrosis and intrinsic obstruction caused by a calculus in the excretory pathway. Differential diagnosis can only be made when the ultrasound directly shows the presence of calculi in the pyelo-ureteral 4 junction or in the frst portion of the lumbar ureter. Whatever the cause, renal colie pain should be treated as a matter of urgency. Minimal or non-invasive imaging tech- niques are preferred. The inflammation of the fascia overlying the neighboring organs ccan be distinguished by MRI. Anatomical imaging evidence is extremely valuable in differential diagnosis (9.10), Urological complications in pregnancy are caused by pain and can take the form of uterine contractions and fetal distress. If urine is infected, there may be bacteremia, septicemia, or even toxic-septic shock that ‘may result in fetal and even materual death, ‘A rare, but very severe complication is the spontaneous rupture of the kidney that is often fatal (L1, 12, 13, 14). CONCLUSIONS In our study the clinical picture of the patients is almost like the manifestations of other urological diseases; differences that ccan occur in the disease course and compli- cations could affect both the mother and the fetus. Our statistical data show that the incidence of urological diseases during pregnancy is significantly higher in primip- aras women, The imaging investigations should be performed due to the possible harmful effects on the product of concep- tion. In the studied group we were able to ‘make an ultrasound diagnosis so that it was not necessary to use X-rays in any case, The renal colic will be initially treated conservatively by controlled ingestion of fluids, antalgic and antispasmodic drugs, and in the case of hyperalgesicor febrile colic the emergency drainage of the upper urinary tract, most commonly performed by ureteral catheterization of percutaneous ‘nephrostomy,‘Management of renal colle during preguaney REFERENCES 1, Loughlin KR, Management of urologic problems during pregnancy. Humana Press In.,2004, 1-3. 2 Dominique RM, Kimberly LF, Benjamin MB,Urologic and Gynecologic Sources of Pelvic Pain, Physical Medicine and Rehabilitation Clinics of North America 2017; 28(3): 571-588 3. Stanton SL, Keer-Wilson R, Barris GV. The incidence of wological symptoms in normal pregnancy. Br J Obstet Gynaecol 1980; $7: £97-900. 4. Gorton E, Whitfield HN. Renal calult in pregnancy. J Urol1997; SO(Suppl 1): 449. 5. 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Rocha et al, the effect of adding elecitical impedance spectroscopy (EIS) ‘measurement at baseline to suspicious melanoestic lesions undergoing routine short-term se- quential digital dermoseopy imaging (SDDI) was assessed, Patients with suspicious melano- évtic lesions eligible for short-term SDDI were evaluated with EIS measurement which was performed atthe first visit following SDI. Melanoeytic lesions with an EIS score > 7 were excised becuse of te high risk of melanoma while lesions with a score < 7 were monitored ‘with standard SDDI over a 3-month period. The results showed that an EIS score < 3 re- 4quires no SDDI and values > 7 requite immediate excision of melanocytic lesions reducing the need for SDDI. The study offered # new approach to skin cancer diagnosis and showed Uust mew protocol combining EIS at baseline with SDDI reduced the need fo proceed to SDDI in just under half of eases. (Rocha T., Menzies S.W.. Lo S. otal. Analysis of an elec trical impedance spectroscopy system in short-term digital dermoscopy of melanocytic le- sions. B/D 2017 Oet. 11. doi10.111Lbjd. 15595), Joana Alina Grajdcara us